All UM decisions and coverage of service decisions are consistent with Vaya’s Clinical Practice Guidelines(approved 02/19/2019). Clinical practice guidelines are designed to guide providers on how to follow national and community standards of practice. Clinical practice guidelines are not a substitute for the advice of a healthcare professional or the UM reviewer or peer reviewer making medical necessity determinations.

Vaya adopts
guidelines that are based on valid and reliable clinical evidence
(evidence-based practices) or a consensus of licensed professionals. We also
may adopt clinical practice guidelines promulgated by nationally recognized
peer review organizations such as the American Psychiatric Association (APA),
the American Academy of Child Psychiatrists (AACAP), the Substance Abuse and
Mental Health Services Administration (SAMHSA), the Veterans Administration
(VA), the Center for Child and Family Health, the British National Institute
for Health and Clinical Excellence, the Agency for Healthcare Research and
Quality (AHRQ), the National Institute of Mental Health (NIMH) and the National
Center on Birth Defects and Developmental Disabilities.

Network providers are required to maintain or advance the quality of services through the demonstration of practice consistent with Vaya’s adopted Clinical Practice Guidelines.